Knowledge Base Article

Medicare Transmittals & MLN Articles

March 28, 2025: Transmittal 13079: January 2025 Update of the Ambulatory Surgical Center (ASC) Payment System

Transmittal 13079 replaces Transmittal 13044 that was issued January 10, 2025. The original document has been updated to add an additional requirement and note for MACs for their work implementing the updates. All the other information remained the same. https://www.cms.gov/files/document/r13079cp.pdf

 

April 1, 2025: MLN MM13993: Hospital Outpatient Prospective Payment System: April 2025 Update

This article highlights coding and billing changes for certain lab tests, COVID-19 monoclonal antibody therapy products, and hospital OPPS device categories. It also highlights changes to APCs, surgical and imaging procedures, drugs, biologicals, and radiopharmaceuticals, and skin substitute products.

https://www.cms.gov/files/document/mm13993-hospital-outpatient-prospective-payment-system-april-2025-update.pdf

 

April 3, 2025: MLN MM13990: DMEPOS Fee Schedule: April 2025 Quarterly Update

CMS advises that your billing staff needs to know about new HCPCS codes, new fee schedule amounts, new HCPCS codes on the fee schedule file for DMEPOS repairs and servicing, complex rehabilitative power wheelchair accessories, and lymphedema compressions treatment items. https://www.cms.gov/files/document/mm13990-dmepos-fee-schedule-april-2025-quarterly-update.pdf

 

April 25, 2025: MLN MM14017: Ambulatory Surgical Center Payment System: April 2025 Update

CMS advised that your billing staff be aware of updates effective April 1, 2025 (i.e., a new HCPCS code for simulation angiogram for radioembolization of tumors). https://www.cms.gov/files/document/mm14017-ambulatory-surgical-center-payment-system-april-2025-update.pdf

 

Coverage Updates

March 19, 2025: Transcatheter Tricuspid Valve Replacement (TTVR) Final Decision Memo (CAG-00467N)

CMS now covers TTVR for the treatment of symptomatic tricuspid regurgitation (TR) under Coverage with Evidence Development (CED) when provisions in the Decision Memo are met for patient, physician, and CED study criteria. Specific to that patient, it is covered when “despite optimal medical therapy (OMT), patients must have symptomatic TR with tricuspid valve replacement being considered as appropriate by a heart team.” The heart team, at a minimum, must include a cardiac surgeon, interventional cardiologist, cardiologist with training and experience in heart failure management, electrophysiologist, multi-modality imaging specialists, and an interventional cardiographer. “All of the specialists listed above must have experience in the care and treatment of tricuspid regurgitation.” CMS also notes that “all CMS-approved CED studies must meet the patient and physician criteria. https://www.cms.gov/medicare-coverage-database/view/ncacal-decision-memo.aspx?proposed=N&ncaid=314&fromTracking=Y&

 

March 20, 2025: Change Request (CR) 13939: ICD-10 and Other Coding Revisions to National Coverage Determinations (NCDs) – July 2025

This change request provides a quarterly maintenance update of ICD-10 coding conversions and other coding updates specific to NCDs. No policy change is being made. NCDs with updates:

 

NCD 80.2, 80.2.1, 80.3.1: OPT Verteporfin,

NCD 90.2 Next Generation Sequencing,

NCD 100.1 Bariatric Surgery,

NCD 110.18 Aprepitant,

NCD 110.23 Stem Cell Transplants,

NCD 110.24 CAR T-cell Therapy,

NCD 160.18 Vagus Nerve Stimulation,

NCD 210.3 Colorectal Cancer Screening, and

NCD 250.3 IVIG for Treatment Autoimmune Mucocutaneous Blistering Disease.

https://www.cms.gov/files/document/r13097otn.pdf

 

April 3, 2025: Proposed Decision Memo (CAG-00468N) Transcatheter Edge-to-Edge Repair for Tricuspid Valve Regurgitation (T-TEER)

Just under a month after the final decision memo for Transcatheter Tricuspid Valve Replacement (TTVR) was published, CMS released a proposed decision memo for T-TEER procedure. The Benefit Category for this procedure is inpatient hospital services and physicians’ services.

 

Abbott submitted the request for a National Coverage Analysis (NCA) to evaluate this procedure indicating that “The T-TEER procedure is intended to treat patients with symptomatic tricuspid regurgitation (TR). T-TEER procedures are performed percutaneously using a catheter-based technology to approximate the leaflets of the tricuspid valve with a clip device.

 

The T-TEER procedure using Abbott’s TriClip™ system was developed leveraging the experience of the MitraClip™ therapy, which is used to treat mitral valve regurgitation using transcatheter edge-to-edge repair of the mitral valve.”

 

The TripClip™ G4 System received FDA premarket approval on April 1, 2024 as a Breakthrough Device. This system was granted new technology eligible for add-on payment status effective October 1, 2024. The maximum add-on payment for FY 2025 is $26,000.

 

The ICD-10-PCS code used to describe this procedure is 02UJ3JZ (supplement tricuspid valve with synthetic substitute, percutaneous approach). This procedure groups to DRG pair 266/267 (endovascular cardiac valve replacement and supplement procedures with MCC and without MCC respectively).

 

The public comment period for this NCA ends May 3, 2025. https://www.cms.gov/medicare-coverage-database/view/ncacal-tracking-sheet.aspx?ncaid=316

 

Compliance Education Updates

April 2025: MLN Booklet (MLN901705) Telehealth & Remote Patient Monitoring

CMS has updated this MLN booklet including information about some telehealth flexibilities that have been extended through September 30, 2025. https://www.cms.gov/files/document/mln901705-telehealth-remote-patient-monitoring.pdf

 

April 2025: MLN Educational Tool Medicare Preventive Services (MLN006559)

CMS has made changes to preventive screening for colorectal cancer and ultrasound abdominal aortic aneurysm. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#COLO_CAN

 

Other Updates

March 6, 2025: Livanta Publishes Year 3 Review Findings for Higher-Weighted DRG Validation

In their February 2025 edition of “The Livanta Claims Review Advisor,” Livanta shares their higher-weighted diagnosis related groups (HWDRG) validation reviews for reviews completed from November 1, 2023 through October 31, 2024. Of the 6,447 claims found to be in error, 5,744 (10%) were a result of DRG changes and 703 (1%) were a result of failure to meet the guidelines of the Two-Midnight Rule. CMS Region 4 (AL, FL, GA, KY, MS, NC, SC, and TN) have the highest volume of claims reviewed and the highest regional error rate at 14%. For the third review cycle, sepsis DRGs (871 and 872) collectively continue to account for the highest percentage of DRGs found to be in error. Livanta posts their newsletters on their Provider Education and Toolkit webpage at https://www.livantaqio.cms.gov/en/ClaimReview/Provider/provider_education.html. 

 

April 4, 2025: Livanta Published Year 3 Review Findings for Short Stay Reviews (SSRs)

First, as a recap from last month, Livanta published year three review results for higher-weighted diagnosis related groups (HWDRG) reviews on March 6, 2025. Their March 2025 edition of The Livanta Claims Review Advisor focuses on year three review results for short stay reviews (SSRs). For both type of reviews, the third year encompassed reviews completed from November 1, 2023 through October 31, 2024. In year three 14% of claims reviewed resulted in an admission denial. Like HWDRG review results, CMS Region 4 (AL, FL, GA, KY, MS, NC, SC, and TN) had the highest number of claims reviewed and the highest proportion of all denials at 28%. Unlike prior years, Livanta did not list admission types most prone to denial (i.e., cardiac arrhythmia)

 

Overall Review Findings
	Total Claims Reviewed	Approved Claims	Percent of Approved Claims	Admission Denials	Percent of Admission Denials
Year 1	18,672	16,009	86%	2,663	14%
Year 2	21,510	19,375	90%	2,135	10%
Year 3	20,354	17,461	86%	2,893	14%

 

Review Findings by Length of Stay
	All Claims Reviewed	0-day Stay Claims			1-Day Stay Claims
	Number of Claims	Number of Claims Reviewed	Number of Claims Denied	Percent of Claims Denied	Number of Claims Reviewed	Number of Claims Denied	Percent of Claims Denied
Year 1	18,672	5,195	935	18%	13,477	1,887	14%
Year 2	21,510	5,303	716%	14%	16,207	1,419	9%
Year 3	20,354	3,856	915%	24%	16,498	1,978	12%

 

CMS Region with Highest Proportion of All Denials
	CMS Region
	CMS Region	Claims Denied	Claims Reviewed	Regional Error Rate	Proportion of All Denials
Year 1	4	600	4,415	14%	23%
Year 2	4	515	5,077	10%	24%
Year 3	4	797	5,066	16%	28%
CMS Region 4 includes: AL, FL, GA, KY, MS, NC, SC, TN

 

 

April 11, 2025: Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers Final LCDs Delayed

CMS released a notice that they are currently reviewing the coverage policies for skin substitute products and noted that “because of this review, the Skin Substitute Grafts/Cellular and Tissue-Based Products for the Treatment of Diabetic Foot Ulcers and Venous Leg Ulcers Final Local Coverage Determinations effective date will be delayed until January 1, 2026.”

You can review the policies on the Medicare Coverage Database (MCD) at https://www.cms.gov/medicare-coverage-database/basket/basket.aspx?loadBasketLink=Y&basketLinkId=233.

 

April 11, 2025: CMS Issues FY 2026 Proposed Rules and Related Fact Sheets

On April 11, 2025, CMS issued five fiscal year 2026 proposed rules as listed below. The comment period for all five proposed rules ends on June 10, 2025.

 

FY 2026 Hospital Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital Prospective Payment System (LTCH PPS) Proposed Rule – CMS-1833-P: https://www.cms.gov/newsroom/fact-sheets/fy-2026-hospital-inpatient-prospective-payment-system-ipps-and-long-term-care-hospital-prospective

 

FY 2026 Medicare Inpatient Psychiatric Facility Prospective Payment System and Quality Reporting Updates Proposed Rule CMS-1831-P: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2026-medicare-inpatient-psychiatric-facility-prospective-payment-system-and-quality

 

FY 2026 Inpatient Rehabilitation Facility Prospective Payment System Proposed Rule CMS-1829-P: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2026-inpatient-rehabilitation-facility-prospective-payment-system-proposed-rule-cms-1829

 

April 11, 2025: FY 2026 Skilled Nursing Facility Prospective Payment System Proposed Rule 1827-P: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2026-skilled-nursing-facility-prospective-payment-system-proposed-rule-cms-1827-p-fact

 

April 11, 2025: FY 2026 Hospice Wage Index and Payment Rate Update Proposed Rule CMS-1835-P: https://www.cms.gov/newsroom/fact-sheets/fiscal-year-2026-hospice-wage-index-and-payment-rate-update-proposed-rule-cms-1835-p-fact-sheet